My mother lived to just weeks short of 90. During the first 89 1/2 years she had a good quality of life, but during the last six months it was very difficult for her and her family. Having spent a lot of time with her between the assisted living home and the hospital, I learned a lot about healthcare for patients with chronic heart failure. For those over 65, somewhere between 6 and 10% have CHF and the estimated annual expenditure for their care and treatment is $35 billion.
A typical scenario would be for an 89 year old person to enter the emergency department with shortness of breath. After a few hours or more in the ED the patient is admitted to the cardiac care unit. The patient is taking a dozen or so medications which are changed by the hospitalist to conform to the hospital formulary. After a week of tests, fluid infusion, and monitoring, the patient is ready to be discharged back to a nursing or assisted living home. The goal is to have the primary care physician see the patient within a week to make sure he or she is on track to stable health. The patient is confused about the new medications they have been discharged with and the appointment with the PCP may or may not happen in a week. Things go fine for a few weeks and then it is back to the ED and a readmission to the hospital. Repeat.
There are many long term solutions involving diet, exercise, and medications, but in the meantime there are millions of people with CHF who will likely follow the scenario above. Is it possible that using home monitoring can have a positive impact on quality of life and reduced healthcare expenditures? The jury is out. Research studies are underway at distinguished medical centers around the country. The idea is that by monitoring weight, blood oxygen, blood pressure and some basic questions like “How do you feel today?”, “Did you take your medications?”, etc., a stream of data is created every day that may be predictive of what is ahead. A recent study by Yale and reviewed in the New England Journal of Medicine concluded there was no difference in outcomes between those under monitoring and those not. I read the study and found that my idea of “monitoring” is different than what their study used. Although many experts were involved in the study, the data collection was done by the patients calling an automated telephone service and entering data. That is not monitoring from my perspective. Apparently it wasn’t for some of the patients in the study either because many did not enter their data.
Major companies including GE, Intel, IBM, and others are putting millions of dollars into research and development in the telemedicine market. I visited a lady in Connecticut that was being monitored by equipment provided by the Visiting Nurses Association. It was basically a PC with plug-in measuring devices. Each day the patient interacts with the PC and answers a couple of dozen questions in addition to providing weight O2, and blood pressure measurements. What struck me about the visit was not the technology but the social aspects of the process. The lady was “attached” to the PC — not technically but emotionally. She was taking responsibility for her health. She had previously been called a “frequent flier” by people at the ED. Now she doesn’t visit so often. Maybe she fears being away from her PC? The PC had become her buddy. It was Facebook to her. Some studies have shown that a person being monitored will fess up to having had a fall which they would not have told a nurse about for fear of being told they would have to go to the ED to be checked.
The data collected by the PC is sent through a dial-up telephone connection to a monitoring center, much like an alarm center. I can envision vast improviements to the system being used today. Instead of a big clunky PC how about something the size of an iPhone? O2, blood pressure cuff, and scale all connected by wireless. Data transmitted via broadband in realtime. Data going to a patient-centered medical home facility where a resident scans the data rather it going to an alarm center. Supercomputer analytics being applied to the data to look for patterns between weight, O2, blood pressure, and answers to various questions with the result being a prediction of fluid buildup that will lead to problems in 6 days unless the intake of diuretics is increased by 50% for ten days. Compared to the monitoring and predictions that are made by NASA for a spacecraft, the monitoring and predictions made for CHF patients is archaic. Skeptics say that there are too many factors involved and that only a doctor can make sense of them. I have the utmost respect for physicians but I also know, as sure as I can spell my name, that a few years from now we will be asking why it took so many years to realize that complications of various chronic diseases are in fact related to data that is collectible and very nicely subject to sophisticated analytics which can improve the quality of life and dramatically lower cost.
Milt Freudenheim at the New York Times summarizes many of the issues with home monitoring in his story Wired Up at Home to Monitor Illnesses. It is an excellent story that I can highly recommend reading.